A 42-year-old woman on oral contraceptives presents with sudden abdominal pain, ascites, and tender hepatomegaly. Doppler ultrasound shows absent flow in all three major hepatic veins with an intrahepatic collateral 'spider web' pattern. Liver biopsy would be expected to show:

• A Portal tract fibrosis with ductular proliferation and copper deposition
• B Zone 3 sinusoidal congestion with centrilobular necrosis and reverse lobulation ✓
• C Massive panlobular necrosis with collapsed reticulin framework
• D Perisinusoidal fibrosis with ballooned hepatocytes in zone 3

Explanation

Budd-Chiari syndrome results from thrombosis of the hepatic veins, commonly associated with myeloproliferative neoplasms, oral contraceptives, pregnancy, and thrombophilic states. Obstruction of venous outflow produces severe zone 3 (centrilobular) sinusoidal congestion, hepatocyte atrophy and necrosis, and eventually bridging fibrosis. With chronicity, regenerative nodules around preserved portal areas create a reversed lobulation pattern resembling cardiac cirrhosis. Massive panlobular necrosis describes fulminant hepatitis, perisinusoidal fibrosis with ballooning describes steatohepatitis, and ductular proliferation with copper suggests chronic cholestasis.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.